Locate your assigned case study and answer the questions which correspond to the FIRST letter of your LAST name. Then you will respond to the main postings of two other learners; at least one response should be to a peer who has answered questions different from yours.
Aebin NewsomOct 16 8:40am| Last reply Oct 16 4:21pm
Reply from Aebin Newsom
Initial Post
Based upon the patient’s presentation and historical data provided I would advise a few modifications to this patient’s treatment plan that are within the scope of practice of a PMHNP in Florida. Firstly, I would recommend that we make changes to her medication regimen. The patient reports that she “gained 25 lbs” since starting Abilify and had to increase her dose of Ozempic and atorvastatin. One of the key potential metabolic side effects of using atypical antipsychotics, especially second-generation antipsychotics, is weight gain (Skonieczna-Zydecka et al., 2020). In circumstances in which patients gain a lot of weight from using an atypical antipsychotic, research evidence suggests that discontinuing that medication or switching to a different medication like bupropion or an SSRI may help to mitigate the negative metabolic effects of the atypical antipsychotic (Hakami et al., 2022).
Secondly, I would refer the patient for dialectical behavioral therapy, cognitive behavioral therapy, and grief counseling. The patient reports that her anxiety and depression started after the unfortunate death of her husband and have remained since then. This indicates that there are likely some ineffective coping strategies in place, and the patient may benefit from professional counseling. This is especially important considering that the patient stated that her anxiety keeps her from going out alone and walking daily for exercising.
Lastly, I would call the office of her primary care provider in a collaborative effort to address her underlying metabolic risk, rather than adjusting these medications myself. Despite being on a therapeutic dose of “atorvastatin for 7 years, Ozempic for three years, and lisinopril for 10 years”, her cholesterol, overall lipid panel, blood pressure, and hemoglobin A1C are much too elevated. Given her history and current lab values, she is at a moderate to high risk of developing cardiovascular disease and having a stroke and/or heart attack.
References
Hakami, A. Y., Felemban, R., Ahmad, R. G., Al-Samadani, A. H., Salamatullah, H. K., Baljoon, J. M., Alghamdi, L. J., Ramadani Sindi, M. H., & Ahmed, M. E. (2022). The association between antipsychotics and weight gain and the potential role
of metformin concomitant use: A retrospective cohort study. Frontiers in Psychiatry, 13, 914165. https://doi.org/10.3389/fpsyt.2022.914165
Skonieczna-Zydecka, K., Loniewski, I., Stachowska, E., Marlicz, W., & Correll, C. U. (2020). Current and novel approaches to mitigate cardiometabolic adverse effects of second-generation antipsychotics.
The International Journal of Neuropsychopharmacology, 23(8), 491–495. https://doi.org/10.1093/ijnp/pyaa026
Ralph AnnamOct 15 11pm| Last reply Oct 18 1:35am
Reply from Ralph Annam
Objective and Subjective Information
The patient is a 70-year-old woman who has high blood pressure, high blood sugar, slight obesity, and high cholesterol. She also has sadness and anxiety that started after her husband died seven years ago. She says she is still worried about going out alone, does not socialize much, and has trouble losing weight even though she records what she eats. She has gained 25 pounds since starting Abilify 5 mg a day and now has desires for carbs.
Current Medications: Atorvastatin 20 mg, Ozempic 1 mg once a week, lisinopril 10 mg, and Abilify 5 mg.
Vitals and labs: Height: 5'2", weight: 176 lbs, BMI: 32.2, blood pressure: 146/83, fasting blood glucose: 115 mg/dL, HbA1C: 6.9%, total cholesterol: 200 mg/dL, LDL: 100 mg/dL, and HDL: 37 mg/dL.
Evaluation: Abilify is linked to mild weight gain, which may make this patient's weight gain and metabolic risk factors worse. Her anxiousness and lack of movement also make her weight and metabolic problems worse. The depression has only gotten better.
Plan / Suggestions
1. Changing the dose of psychotropic drugs:
Gradually decreasing off Abilify and switching to a weight-neutral SSRI like sertraline or escitalopram may help with mood and anxiety symptoms while also reducing metabolic adverse effects. Older adults generally tolerate SSRIs well and have a reduced risk of weight gain (Bishara & Taylor, 2022; Gelenberg et al., 2022). In most U.S. states, PMHNPs can write prescriptions for SSRIs on their own (AANP, 2024).
2. Behavioral Activation and Lifestyle Interventions: To help with weight loss, lower anxiety, and better glycemic control, encourage a daily walking practice, preferably with a friend or a walking group. There is substantial evidence that behavioral activation can help older people feel better and obtain them moving (Dimidjian et al., 2017; Colberg et al., 2016).
3. Collaborative Care: Work with her primary care doctor or endocrinologist to review her Ozempic regimen and determine the best way to control her glucose and cholesterol levels. Consider sending her to cognitive behavioral therapy (CBT) for anxiety to help her become more independent and participate in social activities (Stanley et al., 2020).
References
American Association of Nurse Practitioners. (2024). State practice environment. https://www.aanp.org
Bishara, D., & Taylor, D. (2022). Adverse effects of antipsychotic medication. Advances in Psychiatric Treatment, 28(1), 36–45.
Colberg, S. R., et al. (2016). Physical activity/exercise and diabetes. Diabetes Care, 39(11), 2065–2079.
Dimidjian, S., et al. (2017). Behavioral activation treatments for depression. Annual Review of Clinical Psychology, 13, 1–25.
Gelenberg, A. J., et al. (2022). Practice guideline for the treatment of patients with major depressive disorder.
Stanley, M. A., et al. (2020). CBT for late-life generalized anxiety disorder. Am J Geriatr Psychiatry, 28(2), 143–154.
